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Heart failure symptom management

  • NCLEX-RN
  • NCLEX-PN
  • Physiological Adaptation
  • Bow-tie
  • Difficulty 3 of 5

Question

Complete the diagram by choosing the condition the client is most likely experiencing, 2 actions to take and 2 parameters to monitor.

Actions to takeSelect 2

  • Help the client rest with the head raised✓ Correct
  • Space dressing tasks with rest breaks✓ Correct
  • Keep the client flat for sleep✗ Incorrect
  • Keep the client continuously active✗ Incorrect

Condition most likely experiencingSelect 1

  • Heart failure symptoms✓ Correct
  • Resolved heart failure✗ Incorrect
  • Isolated skin infection✗ Incorrect
  • Medication allergy✗ Incorrect

Parameters to monitorSelect 2

  • Breathlessness during usual activity✓ Correct
  • Daily body weight✓ Correct
  • Hair length✗ Incorrect
  • Visual acuity for reading✗ Incorrect

Answer

Actions to take: Help the client rest with the head raised; Space dressing tasks with rest breaks · Condition most likely experiencing: Heart failure symptoms · Parameters to monitor: Breathlessness during usual activity; Daily body weight

Rationale

Difficulty breathing when flat and fatigue fit the client’s known cardiac condition. Upright rest and pacing activities address the symptoms while weight and breathing trends help identify deterioration.

RememberFor heart failure, follow breathing and weight trends and pace activity.

Sources

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